Task-oriented training in rehabilitation after stroke: systematic review

EEG classification of different imaginary movements within the same limb

The task of discriminating the motor imagery of different movements within the same limb using electroencephalography (EEG) signals is challenging because these imaginary movements have close spatial representations on the motor cortex area. There is, however, a pressing need to succeed in this task. The reason is that the ability to classify different same-limb imaginary movements could increase the number of control dimensions of a brain-computer interface (BCI). In this paper, we propose a 3-class BCI system that discriminates EEG signals corresponding to rest, imaginary grasp movements, and imaginary elbow movements. Besides, the differences between simple motor imagery and goal-oriented motor imagery in terms of their topographical distributions and classification accuracies are also being investigated. To the best of our knowledge, both problems have not been explored in the literature. Based on the EEG data recorded from 12 able-bodied individuals, we have demonstrated that same-limb motor imagery classification is possible. For the binary classification of imaginary grasp and elbow (goal-oriented) movements, the average accuracy achieved is 66.9%. For the 3-class problem of discriminating rest against imaginary grasp and elbow movements, the average classification accuracy achieved is 60.7%, which is greater than the random classification accuracy of 33.3%. Our results also show that goal-oriented imaginary elbow movements lead to a better classification performance compared to simple imaginary elbow movements. This proposed BCI system could potentially be used in controlling a robotic rehabilitation system, which can assist stroke patients in performing task-specific exercises.

Effect of task-oriented training for people with stroke: a meta-analysis focused on repetitive or circuit training

PURPOSE

The current meta-analysis reviewed evidence for effective task-oriented training focused on repetitive or circuit training after stroke.

METHOD

Searches were conducted of randomized, controlled trials using task-oriented training. The quality of each study was assessed using the Physiotherapy Evidence Database (PEDro) scale. Eleven studies were analyzed regarding the magnitude of effect sizes (ESs) and categorized according to extremities focused upon for training, outcome measures, and study variables. This included duration and frequency of training and stroke stage.

RESULTS

The PEDro scores ranged from 4 to 8 (median = 7). The overall ES of the 11 studies was large. The effects for lower extremities and both acute/sub-acute and chronic stage stroke were large and significant. Significant effects were also found for gait velocity, gait endurance, balance, timed up and go test, and strength of the lower extremities. There was no significant effect of training focused on upper extremities. Training with a duration of 2 weeks and frequency of 7 days a week had the greatest effects.

CONCLUSIONS

Task-oriented training interventions are useful for improving muscle strength and gait related activities in both acute/sub-acute and chronic stroke patients. Although this meta-analysis provides evidence of task-oriented training for improving functioning after stroke, further studies are necessary to investigate the effects of training on upper extremities and the overall cost-effectiveness of such training.

The effect of class-based task-oriented circuit training on the self-satisfaction of patients with chronic stroke

[Purpose] This study aimed to determine the difference in self-satisfaction in patients by comparing class-based task-oriented circuit training (CTCT) and individual-based task-oriented circuit training (ITCT). [Subjects and Methods] The subjects were 30 patients who had been diagnosed with hemiplegia due to stroke more than six month previously. They were divided into Group I (n=9) for conventional therapy, Group II (n=10) for conventional therapy and ITCT, and Group III (n=11) for conventional therapy and CTCT. In order to determine self-satisfaction as a psychological factor in patients, we used a self-esteem scale (SES), motivation of rehabilitation scale (MR), and relationship change (RCS) scale. [Results] SES, MR, and RCS, which were measured to determine self satisfaction as a psychological factor were significantly different between groups. The Bonferroni post hoc test revealed a significant difference between Group I and Group III in SES, a significant difference between Group I and Group III and Group II and Group III in MR, and a significant difference between Group I and Group III were found. [Conclusion] Based on the above results, task-oriented circuit training was more effective when performed in a class than when performed individually in terms of self-satisfaction. Based on this result, we determined that CTCT has as positive an effect on the mental aspects of stroke patients compared with ITCT.

Variations in apolipoprotein D and sigma non-opioid intracellular receptor 1 genes with relation to risk, severity and outcome of ischemic stroke

BACKGROUND

In experimental studies, the apolipoprotein D (APOD) and the sigma receptor type 1 (SIGMAR1) have been related to processes of brain damage, repair and plasticity.

METHODS

We examined blood samples from 3081 ischemic stroke (IS) patients and 1595 control subjects regarding 10 single nucleotide polymorphisms (SNPs) in the APOD (chromosomal location 3q29) and SIGMAR1 (chromosomal location 9p13) genes to find possible associations with IS risk, IS severity (NIHSS-score) and recovery after IS (modified Rankin Scale, mRS, at 90 days). Simple/multiple logistic regression and Spearman's rho were utilized for the analyses.

RESULTS

Among the SNPs analyzed, rs7659 within the APOD gene showed a possible association with stroke risk (OR = 1.12; 95% CI: 1.01-1.25; P = 0.029) and stroke severity (NIHSS ≥ 16) (OR = 0.70; 95% CI: 0.54-0.92; P = 0.009) when controlling for age, sex and vascular risk factors for stroke. No SNP showed an association with stroke recovery (mRS).

CONCLUSIONS

We conclude that the SNP rs7659 within the APOD gene might be related to risk and severity of ischemic stroke in patients.

Rethinking Rehab: Skill-Based Training for Swallowing Impairment

Current rehabilitation approaches for swallowing impairment are limited by a general lack of specificity to associated pathophysiology, with many of our practices focusing on increasing strength of muscle activation. However, alternative rehabilitative options are emerging. One of these speculates on the concept of “skill training” for swallowing rehabilitation in neurogenic dysphagia. The presumed intent of this approach is to modulate neural substrates and refine motor planning for swallowing using intrinsically generated cortical modulation and adaptive practice. This manuscript provides a discussion of skill training in the context of physical rehabilitation, illustrating how this information may translate to the diagnosis and remediation of swallowing impairment. This information prompts the consideration of more diverse swallowing pathophysiologies, beyond peripheral muscle weakness. The focus on skill training approaches provides a pathway by which greater specificity of diagnosis and treatment can occur.

Deep flexion activity training in a patient with stroke using task-oriented exercise: a case report

BACKGROUND AND PURPOSE

Many individuals with stroke express desires to resume activities involving deep knee flexion, such as daily living, work-related, and sports activities. However, training methods for improving deep flexion activities have not commonly been reported in the stroke rehabilitation literature. The purpose of this case report is to describe the development of a task-oriented training program and demonstrate its use in improving deep flexion activities in an individual with sub-acute hemiplegia.

CASE DESCRIPTION

The patient was a 55-year-old shoe salesman diagnosed with ischemic stroke 6 weeks before physical therapy evaluation. His primary concerns were functional activities that required deep flexion, such as the inability to squat and to maintain a squatting position in the Eastern toilet and difficulty in performing work-related activities (e.g. fitting shoes for customers while sitting on a low stool).

INTERVENTION

We developed a task-oriented training program that specifically targeted deep flexion activities. The first phase of training consisted primarily of practicing sit-to-stand on a low stool and the second phase consisted of practicing squatting.

OUTCOMES

After 6 weeks of intervention, the patient achieved more than the expected outcome on the Goal Attainment Scale (score = +2) for both primary goals and reported positive changes in social participation, such as visiting his friends and relatives and praying at the temple.

DISCUSSION

The task-oriented deep flexion activity intervention was associated with positive changes in functional activity and social participation in a patient recovering from stroke.

Nursing practice in stroke rehabilitation: systematic review and meta-ethnography

AIMS AND OBJECTIVES

To identify and synthesise the available research evidence in order to generate an explanatory framework for nursing practice in stroke rehabilitation.

BACKGROUND

Although nurses are the largest professional group working with stroke survivors, there is limited understanding of nursing practice in stroke units. In particular, there is currently very little evidence in respect of nurses' involvement in poststroke rehabilitation.

DESIGN

Meta-ethnography.

METHOD

A systematic review was undertaken. The review question was: 'What is the nature of nursing practice in the care and rehabilitation of inpatient stroke survivors?' Searches of 12 electronic databases identified 14,655 publications, and after screening, 778 remained; 137 papers were obtained and 54 retained for mapping. Sixteen qualitative studies were included in the meta-ethnography.

RESULTS

Nurses' involvement in poststroke rehabilitation was limited. Contextual factors impacted on nurses' perceptions and practice. Nurses' integration of rehabilitation skills was perceived to be contingent on adequate nurse staffing levels and management of demands on nurses' time. Team working practices and use of the built environment indicated separation of nursing and therapy work. Physical care and monitoring were prioritised. Stroke-specific education and training was evident, but not consistent in content or approach. Stroke survivors and families needed help to understand nurses' role in rehabilitation.

CONCLUSION

The review provides compelling evidence that there is an need to re-examine the role of nurses in contributing to poststroke rehabilitation, including clarifying when this process can safely begin and specifying the techniques that can be integrated in nurses' practice.

RELEVANCE TO CLINICAL PRACTICE

Integrating stroke-specific rehabilitation skills in nurses' practice could contribute substantially to improving outcomes for stroke survivors. The explanatory framework developed from the review findings identifies issues which will need to be addressed in order to maximise nurses' contribution to the rehabilitation of stroke survivors.

Development and evaluation of the Primary Healthcare-based Physiotherapy Intervention and its effects on selected indices of stroke recovery

Aim:

To develop a Primary Healthcare-Based Physiotherapy Intervention (PHCPI) that requires simple, inexpensive, easy-to-use equipment for stroke rehabilitation and evaluate its effects on selected clinical indices of recovery among post-acute stroke survivors over a 10-week period.

Methods:

Three databases (Medline, Pubmed and PEDro) were used to identify treatment approaches with proven efficacy. The authors synthesised these treatment approaches to develop the PHCPI, which was used in a repeated measure design involving 25 (mean age=60.6 ± 10.2 years) consenting individuals with first-incidence stroke. These individuals were treated at a primary health centre, twice weekly for 10 consecutive weeks. Outcomes were assessed using the Modified Motor Assessment Scale (MMAS), the Short Form Postural Assessment Scale for Stroke (SF-PASS) and the Reintegration to Normal Living Index (RNLI), before the intervention and fortnightly thereafter. Walking speed and quality of life were also assessed before the intervention and at week 10 of it.

Results:

Within-subject multivariate analysis, after controlling for gender, showed a significant increase in motor function, postural balance, walking speed and quality of life. Their community reintegration scores also improved over the period.

Conclusion:

The PHCPI resulted in improved motor function, community reintegration, walking speed, postural balance and quality of life among community-dwelling stroke survivors. This intervention can be used for stroke rehabilitation at primary health centres.

The effects of post-stroke upper-limb training with an electromyography (EMG)-driven hand robot

Loss of hand function and finger dexterity are main disabilities in the upper limb after stroke. An electromyography (EMG)-driven hand robot had been developed for post-stroke rehabilitation training. The effectiveness of the hand robot assisted whole upper limb training was investigated on persons with chronic stroke (n=10) in this work. All subjects attended a 20-session training (3-5times/week) by using the hand robot to practice object grasp/release and arm transportation tasks. Significant motor improvements were observed in the Fugl-Meyer hand/wrist and shoulder/elbow scores (p<0.05), and also in the Action Research Arm Test and Wolf Motor Function Test (p<0.05). Significant reduction in spasticity of the fingers as was measured by the Modified Ashworth Score (p<0.05). The training improved the muscle co-ordination between the antagonist muscle pair (flexor digitorum (FD) and extensor digitorum (ED)), associated with a significant reduction in the ED EMG level (p<0.05) and a significant decrease of ED and FD co-contraction during the training (p<0.05); the excessive muscle activities in the biceps brachii were also reduced significantly after the training (p<0.05).

Ensuring that education, certification, and practice are evidence based

The occupational therapy profession has put forth a vision for evidence-based practice. Although many practitioners express a commitment to the provision of services informed by evidence, the reality that tradition still determines much of our education, certification, and practice cannot be ignored. In this article, we highlight the disconnect between the profession's aspirations and actual practices using neurophysiological models as an example. We describe actions to actualize the shift from traditional interventions to evidence-based approaches. We challenge readers to become agents of change and facilitate a culture shift to a profession informed by evidence. It is our hope that this article will provoke critical discourse among educators, practitioners, authors, and editors about why a reluctance to let go of unsubstantiated traditions and a hesitancy to embrace scientific evidence exist. A shift to providing evidence-based occupational therapy will enable us to meet the objectives of the Centennial Vision.

Stroke rehabilitation: should physiotherapy intervention be provided at a primary health care centre or the patients' place of domicile?

PURPOSE

This randomized controlled trial compared the outcomes of physiotherapy intervention on selected indices of recovery for stroke survivors treated at a primary health centre group (PHCG) with those treated in their respective places of domicile group (DG).

METHODS

Participants were 52 individuals comprising 24 males and 28 females who had suffered a stroke and were recently discharged from two inpatient health facilities in Ibadan, Nigeria. They were randomly assigned into either the PHCG (n = 25) or DG (n = 27) and treated twice weekly for 10 consecutive weeks using a physiotherapy intervention protocol comprising a battery of task-specific exercises. The outcomes measured were motor function, balance and handicap assessed using the modified motor assessment scale (MMAS), short-form postural assessment scale for stroke (SF-PASS) and reintegration to normal living index (RNLI), respectively, as well as walking speed which was assessed using a standard technique.

RESULTS

Between-group comparison using the General Linear Model revealed no statistically significant difference in both the pre- and post-intervention scores of the two groups on the MMAS, SF-PASS, RNLI and walking speed in both PHCG and DG (p > 0.05). However, within-group comparison yielded a statistically significant difference in each of the indices of stroke recovery measured across the 10-week period in both groups.

CONCLUSION

Physiotherapy intervention at the primary health care centre and respective homes of stroke survivors similarly improved clinical outcomes. Treatment at any of these locations may enhance access to physiotherapy after stroke in a low-income community like Nigeria.

IMPLICATIONS FOR REHABILITATION

Physiotherapy protocol comprising 10-week task-specific battery of exercises produced significant improvement in walking speed, balance, motor function and community reintegration of stroke survivors. Physiotherapy post-stroke can be provided at either a primary health centre or the domicile of the individual. In a low-income country like Nigeria, this will enhance access to this important service.

The power of home rehabilitation: a single case study

This single case study reports on an 81-year-old woman who underwent a rehabilitation programme initially in a hospital inpatient setting, then in a home setting. There was a clinically significant improvement in functional outcomes following the home-based rehabilitation, but not following the inpatient rehabilitation programme. This case study illustrates that empowerment of the patient may sometimes be greater in the home environment, possibly due to different roles taken by the patient and therapist in the home compared with roles taken in a hospital environment. This patient reported feelings of being in more control at home, with greater capacity to set their own goals, and improved feelings of motivation with this increased level of engagement. This increased empowerment can lead to more effective outcomes for patients undergoing rehabilitation in the home, and must be considered as an ideal rehabilitation environment for some patients.

Functional exercise and physical fitness post stroke: the importance of exercise maintenance for motor control and physical fitness after stroke

It is argued that all stroke patients, indifferent of disability, have the same possibility to improve with training. The aim of the study was to follow and register functional improvements in two groups with different functional capacities at baseline for a period of 36 months. Stroke patients were recruited and divided into groups related to their functional status at baseline. During the acute rehabilitation, both groups received functional task-oriented training, followed by regular self- or therapeutic driven training the first year after stroke and varied exercise patterns the following 24 months. The participants were tested on admission, and at three, six, twelve, and thirty-six months after the onset of stroke. Both groups improved functional activity up to six months which then stabilized up to twelve months to decline somewhat at thirty-six months after stroke. Change scores indicate a greater potential for rehabilitation in the MAS ≤35 in relation to group MAS >35 although the functional capacity was higher in the latter. This indicates the importance of maintaining exercise and training for all persons after stroke.

Disparities in postacute rehabilitation care for stroke: an analysis of the state inpatient databases

OBJECTIVE

To determine the extent to which sociodemographic and geographic disparities exist in the use of postacute rehabilitation care (PARC) after stroke.

DESIGN

Cross-sectional analysis of data for 2 years (2005-2006) from the State Inpatient Databases.

SETTING

All short-term acute-care hospitals in 4 demographically and geographically diverse states.

PARTICIPANTS

Individuals (age, ≥45y; mean age, 72.6y) with a primary diagnosis of stroke who survived their inpatient stay (N=187,188). The sample was 52.4% women, 79.5% white, 11.4% black, and 9.1% Hispanic.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

(1) Discharge to an institution versus home. (2) For those discharged to home, receipt of home health (HH) versus no HH care. (3) For those discharged to an institution, receipt of inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) care. Multilevel logistic regression analyses were conducted to identify sociodemographic and geographic disparities in PARC use, controlling for illness severity/comorbid conditions, hospital characteristics, and PARC supply.

RESULTS

Blacks, women, older individuals, and those with lower incomes were more likely to receive institutional care; Hispanics and the uninsured were less likely. Racial minorities, women, older individuals, and those with lower incomes were more likely to receive HH care; uninsured individuals were less likely. Blacks, women, older individuals, the uninsured, and those with lower incomes were more likely to receive SNF versus IRF care. PARC use varied significantly by hospital and geographic location.

CONCLUSIONS

Several sociodemographic and geographic disparities in PARC use were identified.

A critical threshold of rehabilitation involving brain-derived neurotrophic factor is required for poststroke recovery

BACKGROUND

Enriched rehabilitation (ER; environmental enrichment plus skilled reaching) improves recovery after middle cerebral artery occlusion (MCAo) in rats. Fundamental issues such as whether ER is effective in other models, optimal rehabilitation intensity, and underlying recovery mechanisms have not been fully assessed.

OBJECTIVE

The authors tested whether the efficacy of ER varies with ischemia model and assessed the importance of rehabilitation intensity and brain-derived neurotrophic factor (BDNF) in recovery.

METHODS

Rats in experiment 1 received 8 weeks of ER or remained in standard housing. Functional outcome was assessed with the staircase and cylinder tasks. Surprisingly, ER provided no functional benefit in any model. In this experiment, ER was delivered during the light phase, whereas other studies delivered ER in the dark phase of the light cycle. It was hypothesized that in the light, rats engaged in less rehabilitation or alternatively that BDNF was lower. Experiment 2 tested these hypotheses. Following MCAo, rats received ER in either the light or dark phase of the light cycle. Functional outcome was assessed and BDNF levels were measured in the motor cortex and hippocampus.

RESULTS

Recovery was accompanied by increased BDNF. This occurred only in rats that received ER in the dark and these animals reached more than those in the light condition.

CONCLUSIONS

Data suggest that there is a critical threshold of rehabilitation, below which recovery will not occur, and that BDNF mediates functional recovery. The use of intensive rehabilitation therapies for stroke patients is strongly supported.

Effects of recombinant growth hormone replacement and physical rehabilitation in recovery of gross motor function in children with cerebral palsy

Cerebral palsy is an important health issue that has a strong socioeconomic impact. There is no cure for cerebral palsy, and therapeutic approaches only report small benefits for affected people. In this study we assessed the effects of growth hormone treatment (0.3 μg/kg/day) combined with physical rehabilitation in the recovery of gross motor function in children with growth hormone deficiency and cerebral palsy (four males and six females, mean age 5.63 ± 2.32 years) as compared with that observed in a similar population of cerebral palsy children (five males, five females, mean age 5.9 ± 2.18 years) without growth hormone deficiency treated only with physical rehabilitation for two months. The Gross Motor Function Measure (GMFM-88) and Modified Ashworth Scale were performed before commencing the treatment and after completion thereof. In children with cerebral palsy and growth hormone deficiency, Dimension A (P < 0.02), dimension B (P < 0.02), and dimension C (P < 0.02) of the GMFM-88, and the total score of the test (P < 0.01) significantly improved after the treatment; dimension D and dimension E did not increase, and four of five spastic patients showed a reduction in spasticity. However, in children with cerebral palsy and without growth hormone deficiency, only the total score of the test improved significantly after the treatment period. This indicates that growth hormone replacement therapy was responsible for the large differences observed between both groups in response to physical rehabilitation. We propose that the combined therapy involving growth hormone administration and physical rehabilitation may be a useful therapeutic approach in the recovery of gross motor function in children with growth hormone deficiency and cerebral palsy.

Effects of growth hormone (GH) replacement and cognitive rehabilitation in patients with cognitive disorders after traumatic brain injury

OBJECTIVE

To assess the effects of growth hormone (GH) treatment combined with cognitive rehabilitation in patients with adult growth hormone deficiency (GHD) and cognitive disorders occurring after traumatic brain injury (TBI).

PARTICIPANTS

Nineteen adult patients with TBI: GHD was found in 11 of them.

INTERVENTION

Patients were treated with GH (GHD; sc; 1 mg/day) or vehicle (controls; sc; 1 mg/day); daily cognitive rehabilitation therapy was performed in both groups for 3 months.

MAIN OUTCOME MEASURES

The GHRH-arginine test established GHD. The neuropsychological test WAIS was performed before commencing the treatment and 3 months after commencing it.

RESULTS

Controls achieved significant improvements in digits and in manipulative intelligence quotient (IQ) (p < 0.05 vs. baseline). GHD achieved significant improvements in more cognitive parameters: understanding, digits, numbers and incomplete figures (p < 0.05 vs. baseline) and similarities, vocabulary, verbal IQ, manipulative IQ and total IQ (p < 0.01). GHD reached significantly greater improvements than controls in similarities (p < 0.01) and in vocabulary, verbal IQ and total IQ (p < 0.05).

CONCLUSION

GH administration significantly improved cognitive rehabilitation in GHD patients. Since at the end of treatment period plasma IGF-I levels were similar in both groups it is likely that exogenous GH administration is responsible for the significant differences found.

Filling up the hours: how do stroke patients on a rehabilitation nursing home spend the day?

Objective: To describe the time use of stroke patients on rehabilitation units of a nursing home focusing on the time spent on therapeutic activities, non-therapeutic activities, interactions and the location wherein these took place.

Design: A descriptive study.

Setting: Rehabilitation units of a nursing home.

Subjects: Seventeen chronic stroke patients, including 9 men, 8 women, with a mean age of 77 years (SD ± 7.6 years).

Main measures: Daily activities of patients were measured using Behavioural Mapping, including therapeutic activities, non-therapeutic activities, interactions and their location. Functional status was measured with the Barthel Index.

Results. Of the patients 15 (88%) were partly/fully paralysed, with a mean Barthel Index score of 9.4 (SD ± 4.3). The patients spent 20% of the day on therapeutic activities, whereas 80% of the day was spent on non-therapeutic activities; 9% on therapeutic activities with the nurse. For 60% of the day patients were alone and not interacting with others.

Conclusions. Stroke patients spend only short periods of time during the day on therapeutic activities. For the largest part of the day, the patient is alone and passive. A challenge for nurses is how to activate patients and engage them in purposeful task-oriented training in daily activities.